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Kwon W, Hong D, Choi KH, Lee SH, Shin D, Lee JY, Lee SJ, Lee SY, Kim SM, Yun KH, Cho JY, Kim CJ, Ahn HS, Nam CW, Yoon HJ, Park YH, Lee WS, Park TK, Yang JH, Choi SH, Gwon HC, Song YB, Hahn JY, Lee JM. Intravascular Imaging-Guided Percutaneous Coronary Intervention Before and After Standardized Optimization Protocols. JACC Cardiovasc Interv 2024; 17:292-303. [PMID: 38267144 DOI: 10.1016/j.jcin.2023.10.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Although benefits of intravascular imaging (IVI) in percutaneous coronary intervention (PCI) have been observed in previous studies, it is not known whether changes in contemporary practice, especially with application of standardized optimization protocols, have improved clinical outcomes. OBJECTIVES The authors sought to investigate whether clinical outcomes of IVI-guided PCI are different before and after the application of standardized optimization protocols in using IVI. METHODS 2,972 patients from an institutional registry (2008-2015, before application of standardized optimization protocols, the past group) and 1,639 patients from a recently published trial (2018-2021 after application of standardized optimization protocols, the present group) were divided into 2 groups according to use of IVI. The primary outcome was 3-year target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization. RESULTS Significant reduction of TVF was observed in the IVI-guided PCI group compared with the angiography-guided PCI group (10.0% vs 6.7%; HR: 0.77; 95% CI: 0.61-0.97; P = 0.027), mainly driven by reduced cardiac death or myocardial infarction in both past and present IVI-guided PCI groups. When comparing past IVI and present IVI groups, TVF was significantly lower in the present IVI group (8.5% vs 5.1%; HR: 0.63; 95% CI: 0.42-0.94; P = 0.025), with the difference being driven by reduced target vessel revascularization in the present IVI group. Consistent results were observed in inverse-probability-weighting adjusted analysis. CONCLUSIONS IVI-guided PCI improved clinical outcomes more than angiography-guided PCI. In addition, application of standardized optimization protocols when using IVI further improved clinical outcomes after PCI. (Intravascular Imaging- Versus Angiography-Guided Percutaneous Coronary Intervention For Complex Coronary Artery Disease [RENOVATE-COMPLEX-PCI]; NCT03381872; and the institutional cardiovascular catheterization database of Samsung Medical Center: Long-Term Outcomes and Prognostic Factors in Patient Undergoing CABG or PCI; NCT03870815).
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Affiliation(s)
- Woochan Kwon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - David Hong
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Doosup Shin
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Jong-Young Lee
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Jae Lee
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Yeub Lee
- Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea; Chung-Ang University College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | - Sang Min Kim
- Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | | | | | - Chan Joon Kim
- The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Seoul, Korea
| | - Hyo-Suk Ahn
- The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Seoul, Korea
| | | | | | - Yong Hwan Park
- Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Wang Soo Lee
- Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Taek Kyu Park
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Myung Lee
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Sreenivasan J, Reddy RK, Jamil Y, Malik A, Chamie D, Howard JP, Nanna MG, Mintz GS, Maehara A, Ali ZA, Moses JW, Chen S, Chieffo A, Colombo A, Leon MB, Lansky AJ, Ahmad Y. Intravascular Imaging-Guided Versus Angiography-Guided Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Trials. J Am Heart Assoc 2024; 13:e031111. [PMID: 38214263 PMCID: PMC10926835 DOI: 10.1161/jaha.123.031111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 11/13/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Despite the initial evidence supporting the utility of intravascular imaging to guide percutaneous coronary intervention (PCI), adoption remains low. Recent new trial data have become available. An updated study-level meta-analysis comparing intravascular imaging to angiography to guide PCI was performed. This study aimed to evaluate the clinical outcomes of intravascular imaging-guided PCI compared with angiography-guided PCI. METHODS AND RESULTS A random-effects meta-analysis was performed on the basis of the intention-to-treat principle. The primary outcomes were major adverse cardiac events, cardiac death, and all-cause death. Mixed-effects meta-regression was performed to investigate the impact of complex PCI on the primary outcomes. A total of 16 trials with 7814 patients were included. The weighted mean follow-up duration was 28.8 months. Intravascular imaging led to a lower risk of major adverse cardiac events (relative risk [RR], 0.67 [95% CI, 0.55-0.82]; P<0.001), cardiac death (RR, 0.49 [95% CI, 0.34-0.71]; P<0.001), stent thrombosis (RR, 0.63 [95% CI, 0.40-0.99]; P=0.046), target-lesion revascularization (RR, 0.67 [95% CI, 0.49-0.91]; P=0.01), and target-vessel revascularization (RR, 0.60 [95% CI, 0.45-0.80]; P<0.001). In complex lesion subsets, the point estimate for imaging-guided PCI compared with angiography-guided PCI for all-cause death was a RR of 0.75 (95% CI, 0.55-1.02; P=0.07). CONCLUSIONS In patients undergoing PCI, intravascular imaging is associated with reductions in major adverse cardiac events, cardiac death, stent thrombosis, target-lesion revascularization, and target-vessel revascularization. The magnitude of benefit is large and consistent across all included studies. There may also be benefits in all-cause death, particularly in complex lesion subsets. These results support the use of intravascular imaging as standard of care and updates of clinical guidelines.
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Affiliation(s)
| | - Rohin K. Reddy
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Yasser Jamil
- Section of Cardiovascular MedicineYale University School of MedicineNew HavenCTUSA
| | - Aaqib Malik
- Department of CardiologyWestchester Medical Center, New York Medical CollegeValhallaNYUSA
| | - Daniel Chamie
- Section of Cardiovascular MedicineYale University School of MedicineNew HavenCTUSA
| | - James P. Howard
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Michael G. Nanna
- Section of Cardiovascular MedicineYale University School of MedicineNew HavenCTUSA
| | | | - Akiko Maehara
- Cardiovascular Research FoundationNew YorkNYUSA
- Columbia University Medical CenterNew YorkNYUSA
| | - Ziad A. Ali
- Cardiovascular Research FoundationNew YorkNYUSA
- St Francis HospitalRoslynNYUSA
| | - Jeffrey W. Moses
- Cardiovascular Research FoundationNew YorkNYUSA
- Columbia University Medical CenterNew YorkNYUSA
- St Francis HospitalRoslynNYUSA
| | - Shao‐Liang Chen
- Nanjing First HospitalNanjing Medical UniversityNanjingChina
| | - Alaide Chieffo
- Vita Salute San Raffaele UniversityMilanItaly
- IRCCS San Raffaele Scientific InstituteMilanItaly
| | | | - Martin B. Leon
- Cardiovascular Research FoundationNew YorkNYUSA
- Columbia University Medical CenterNew YorkNYUSA
| | - Alexandra J. Lansky
- Section of Cardiovascular MedicineYale University School of MedicineNew HavenCTUSA
| | - Yousif Ahmad
- Section of Cardiovascular MedicineYale University School of MedicineNew HavenCTUSA
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Machanahalli Balakrishna A, Ismayl M, Goldsweig AM, Peters LA, Alla VM, Velagapudi P, Zhao DX, Vallabhajosyula S. Intracoronary Imaging Versus Coronary Angiography Guidance for Implantation of Second and Third Generation Drug Eluting Stents in a Systematic Review and Meta-Analysis of Randomized Controlled Trials. Am J Cardiol 2023; 202:100-110. [PMID: 37423173 DOI: 10.1016/j.amjcard.2023.06.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/11/2023] [Accepted: 06/16/2023] [Indexed: 07/11/2023]
Abstract
Intracoronary imaging (ICI) facilitates stent implant by characterizing the lesion calcification, providing accurate vessel dimensions, and optimizing the stent results. We sought to investigate the outcomes of routine ICI versus coronary angiography (CA) to guide percutaneous coronary intervention (PCI) with second- and third-generation drug-eluting stents. A systematic search of PubMed, Medline, and Cochrane databases was conducted from their inception to July 16, 2022 for randomized controlled trials comparing routine ICI with CA. The primary outcome was major adverse cardiovascular events. The secondary outcomes of interest were target lesion revascularization, target vessel revascularization, myocardial infarction, stent thrombosis, and cardiac and all-cause mortality. A random-effects model was used to calculate the pooled incidence and relative risk (RR) with 95% confidence intervals (CIs). A total of 9 randomized controlled trials with 5,879 patients (2,870 ICI-guided and 3,009 CA-guided PCI) met the inclusion criteria. The ICI and CA groups were similar in demographic characteristics and co-morbidity profiles. Compared with CA, patients in the routine ICI-guided PCI group had lower rates of major adverse cardiovascular events (RR 0.61, 95% CI 0.48 to 0.78, p <0.0001), target lesion revascularization (RR 0.60, 95% CI 0.43 to 0.83, p = 0.002), target vessel revascularization (RR 0.72, 95% CI 0.51 to 1.00, p = 0.05), and myocardial infarction (RR 0.48, 95% CI 0.25 to 0.95, p = 0.03). There were no significant differences in stent thrombosis or cardiac/all-cause mortality between the 2 strategies. In conclusion, routine ICI-guided PCI strategy, compared with CA guidance alone, is associated with improved clinical outcomes, largely driven by lower repeat revascularization.
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Affiliation(s)
| | - Mahmoud Ismayl
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, Department of Medicine, University of Nebraska School of Medicine, Omaha, Nebraska
| | - Luke A Peters
- Section of Cardiovascular Medicine, Department of Medicine and
| | - Venkata M Alla
- Cardiovascular Medicine, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Poonam Velagapudi
- Cardiovascular Medicine, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine and
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine and; Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
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Wulandari AP, Pintaningrum Y, Adheriyani R. Outcomes of optical coherence tomography guided percutaneous coronary intervention against angiography guided in patients with coronary artery disease: A systematic reviews and meta-analyses. Indian Heart J 2023; 75:108-114. [PMID: 36758830 PMCID: PMC10123409 DOI: 10.1016/j.ihj.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/24/2022] [Accepted: 01/29/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Previous studies compared optical coherence tomography (OCT) guided percutaneous coronary intervention (PCI) and angiography-guided was still limited. Therefore, we performed comprehensive meta-analyses to investigate the clinical outcomes of OCT-guided compared with angiography-guided PCI to provide a higher level of evidence. METHODS A systematic search from electronic databases such as Pubmed, EMBASE, SpringerLink, and Cochrane Library was conducted to obtain original articles comparing OCT and angiography. Major adverse cardiac events (MACE), cardiovascular death, myocardial infarction (MI), stent thrombosis, target vessel revascularization, stenosis area, PCI procedure time, contrast volume, and procedural side effects were the measured outcomes. The primary end-points were MACE and cardiovascular death. RESULTS Total 11 studies included 5814 patients were analyzed, with 3431 using OCT-guided and 2383 using angiography-guided. Pooled estimates of outcomes, presented as odds ratios (OR) [95% confidence intervals], were generated with random-effect models. Regarding clinical outcomes, OCT-guided PCI showed significantly lower rate of MACE (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.38 to 0.72, p < 0.001), cardiovascular death (OR 0.47, 95% CI 0.33 to 0.67, p < 0.001), and higher contrast volume (OR 1.6, 95% CI 0.81 to 2.39, p < 0.001). OCT-guided has longer PCI procedure time (OR 2.42, 95% CI 1.33 to 4.42, p = 0.004). OCT-guided has no significant difference in lower risk of periprocedural MI (OR 0.59, 95% CI 0.35 to 1.00, p = 0.05), stent thrombosis (OR 0.69, 95% CI 0.2 to 2.43, p = 0.56), target vessel repeat revascularization (OR 0.74, 95% CI 0.47 to 1.14, p = 0.17), stenosis area (OR -0.63, 95% CI -1.5 to 0.25, p = 0.56), and adverse events related to procedures (OR 1.33, 95% CI 0.8 to 2.19, p = 0.27). CONCLUSION Our meta-analysis demonstrated that OCT-guided PCI is significantly associated with lower MACE, cardiovascular death, and higher contrast volume. It is also associated with a longer duration of PCI. However, it is not associated with MI, stent thrombosis, target vessel revascularization, stenosis area, and adverse events related to procedures.
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Affiliation(s)
- Ayu Pramitha Wulandari
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, Indonesia.
| | - Yusra Pintaningrum
- Division of Interventional Cardiology, Faculty of Medicine, Mataram University, General Hospital of West Nusa Tenggara Province, Mataram, West Nusa Tenggara, Indonesia
| | - Revi Adheriyani
- Cardiology and Vascular Department, Dr. Wahidin Sudiro Husodo, Mojokerto, East Java, Indonesia
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Shibutani H, Fujii K, Shirakawa M, Uchida K, Yamada K, Kawakami R, Imanaka T, Kawai K, Hashimoto K, Matsumura K, Hao H, Hirota S, Shiojima I, Yoshimura S. Diagnostic Accuracy of Optical Frequency Domain Imaging for Identifying Necrotic Cores with Intraplaque Hemorrhage in Advanced Human Carotid Plaques. Am J Cardiol 2021; 156:123-128. [PMID: 34344514 DOI: 10.1016/j.amjcard.2021.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/12/2021] [Accepted: 06/15/2021] [Indexed: 10/20/2022]
Abstract
This study investigated whether optical frequency domain imaging (OFDI) can identify carotid artery vulnerable plaque characteristics, focusing on lipid-rich necrotic core (NC) and intraplaque hemorrhage (IPH). Fourteen patients scheduled for carotid endarterectomy underwent OFDI scan during preoperative angiography. Atherosclerotic plaque specimens obtained from carotid endarterectomy were cut every 3-4 mm into 4-μm transverse cross-sections and stained with standard methods. Each cross-section was matched with OFDI, and histologically classified into either fibrous, calcific, pathological intimal thickening (PIT), and NC. Of 75 histologic cross-sections, 6 were categorized as fibrous (8%), 18 as calcific (24%), 9 as PIT (12%), and 42 as NC (56%). Tissues categorized as NC had significantly higher OFDI signal attenuation rates than the other tissues (p <0.001), followed by PIT, calcific, and fibrous tissues. The receiver operating characteristic analysis indicated that attenuation rates of >0.023 and >0.031 predicted the presence of NC and IPH with high areas under the curve of 0.91 and 0.88, respectively. OFDI provides potential capability for the detection of NCs with IPH of carotid artery plaques by quantitatively analyzing the attenuation rate.
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Abstract
Percutaneous coronary intervention (PCI) has become a standard-of-care procedure in the setting of angina or acute coronary syndrome. Antithrombotic therapy is the cornerstone of pharmacological treatment aimed at preventing ischemic events following PCI. Dual antiplatelet therapy as the combination of aspirin and P2Y12 inhibitor has been proven to decrease stent-related thrombotic risks. However, the optimal duration of dual antiplatelet therapy, an appropriate P2Y12 inhibitor, and the choice of aspirin versus P2Y12 inhibitor as single antiplatelet therapy remain controversial. Furthermore, the combined use of oral anticoagulation in addition to antiplatelet therapy is a complex issue in clinical practice, such as in patients with atrial fibrillation. The key challenge concerning the optimal antithrombotic regimen is ensuring a balance between protection against thrombotic events and against excessive increases in bleeding risk. In this review article, we summarize the current evidence concerning antithrombotic therapy in patients with coronary artery disease undergoing PCI.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
- Yale School of Medicine, USA
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
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Oda H, Itoh T, Sasaki W, Uchimura Y, Taguchi Y, Kaneko K, Sakamoto T, Goto I, Sakuma M, Ishida M, Kikuchi T, Terashita D, Otake H, Morino Y, Shinke T. Cut-off value of strut-vessel distance for the resolution of acute incomplete stent apposition in the early phase using serial optical coherence tomography after cobalt-chromium everolimus-eluting stent implantation. J Cardiol 2020; 75:641-647. [PMID: 31924410 DOI: 10.1016/j.jjcc.2019.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/29/2019] [Accepted: 12/04/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study was to identify a cut-off value to predict the resolution of incomplete-stent-apposition (ISA) after cobalt-chromium everolimus-eluting stent (CoCr-EES) implantation at early follow-up. BACKGROUND To date, appropriate stent apposition at the acute period using intracoronary imaging has been recommended because persistent ISA is considered to be a risk factor for stent thrombosis. We examined the indices for resolving acute ISA. In particular, we determined the cut-off value for strut vessel distance (SV-distance) as visualized by optical coherence tomography (OCT) at 8 months after CoCr-EES implantation. However, the cut-off value of SV-distance for the earlier resolution of ISA is unclear. METHODS A total of 95 cases and 103 stents were registered in the MECHANISM Elective substudy. The SV-distance was measured at the deepest site of the target malapposition and every 1 mm from the proximal edge to the distal edge of the mal-apposed area using OCT. Cut-off values for ISA resolution at 1 and 3 months were estimated by SV-distance using receiver operating characteristic analysis. RESULTS The total number of analyzed struts was 14,418 at the 1-month follow-up and 11,986 at the 3-month follow-up. The optimal SV-distance cut-off values just after stent implantation to predict ISA resolution were 185 µm at the 1-month follow-up and 195 μm at the 3-month follow-up. CONCLUSION For resolution of ISA, SV-distance cut-off values of 185 µm at 1 month postimplantation and 195 μm at 3 months postimplantation can be used as the index of endpoint of the percutaneous coronary intervention.
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Affiliation(s)
- Hideto Oda
- Division of Cardiology, Department of Internal Medicine, Memorial Heart Center, Iwate Medical University, Morioka-city, Iwate, Japan
| | - Tomonori Itoh
- Division of Cardiology, Department of Internal Medicine, Memorial Heart Center, Iwate Medical University, Morioka-city, Iwate, Japan.
| | - Wataru Sasaki
- Division of Cardiology, Department of Internal Medicine, Memorial Heart Center, Iwate Medical University, Morioka-city, Iwate, Japan
| | - Yohei Uchimura
- Division of Cardiology, Department of Internal Medicine, Memorial Heart Center, Iwate Medical University, Morioka-city, Iwate, Japan
| | - Yuya Taguchi
- Division of Cardiology, Department of Internal Medicine, Memorial Heart Center, Iwate Medical University, Morioka-city, Iwate, Japan
| | - Kyosuke Kaneko
- Division of Cardiology, Department of Internal Medicine, Memorial Heart Center, Iwate Medical University, Morioka-city, Iwate, Japan
| | - Tsubasa Sakamoto
- Division of Cardiology, Department of Internal Medicine, Memorial Heart Center, Iwate Medical University, Morioka-city, Iwate, Japan
| | - Iwao Goto
- Division of Cardiology, Department of Internal Medicine, Memorial Heart Center, Iwate Medical University, Morioka-city, Iwate, Japan
| | - Masafumi Sakuma
- Division of Cardiology, Department of Internal Medicine, Memorial Heart Center, Iwate Medical University, Morioka-city, Iwate, Japan
| | - Masaru Ishida
- Division of Cardiology, Department of Internal Medicine, Memorial Heart Center, Iwate Medical University, Morioka-city, Iwate, Japan
| | - Tatsuo Kikuchi
- Department of Cardiology, Edogawa Hospital, Edogawa-ku, Tokyo, Japan
| | - Daisuke Terashita
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kitaharima Medical Center, Ono-city, Hyogo, Japan
| | - Hiromasa Otake
- Division of Cardiology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Chuo-ku, Kobe-city, Japan
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Memorial Heart Center, Iwate Medical University, Morioka-city, Iwate, Japan
| | - Toshiro Shinke
- Division of Cardiovascular Medicine, Showa University School of Medicine, Sinagawa-ku, Kobe, Japan
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